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Home My WebLink AboutDANIEL DENNIS KEY WORKERS' COMPENSATION CLAIM DOCUMENTS IN THE STATE BOARD OF WORKERS' COMPENSATION STATE OF GEORGIA CLAIM NUMBER: 2008-018629 DATE OF INJURY: 04/01/2008 DANIEL DENNIS KEY Employee/Claimant 35 Inglewood Circle St. Helena Island, SC 29920 Phone: 706-664-9777 E-mail: lin49key@gmail.com Employer/Self-Insurer AUGUSTA-RICHMOND COUNTY BOARD OF COMMISSIONERS, AUGUSTA, GEORGIA 530 Greene Street Room 217 Augusta, GA 30901 Phone: 706-821-2302 CORVEL ENTERPRISE COMP INC Claims Office/Servicing Agent 2905 Premier Parkway, Suite 125, Duluth, GA 30097 CHARLES H S LYONS III Counsel for Employer/Self-Insurer 336 Telfair Street Augusta, Ga 30901-2450 Phone: 706/724-6517 4'Aliekett-fp? Fax: 706/724-9954 E-mail: charleslyonslawoffice@comcast.net e7q/ Georgia Bar No. 462340 1JPage THOMAS F. ALLGOOD, JR. Counsel for Employee Allgood &Mehrhof, P.C. 233-B Davis Road Augusta, GA 30907 Phone: 706/724-6526 Fax: 706/724-0043 E-mail: tomallgood@tomallgood.com Georgia Bar No. 012750 Tax ID No.: 58-1624708 STIPULATION AND AGREEMENT WHEREAS, it is the desire of the parties hereto to enter into a total, complete, and irrevocable settlement and extinguishment of the claims of Daniel Dennis Key ("Claimant"), against the Augusta-Richmond County Board of Commissioners (a/k/a Augusta, Georgia and/or Augusta-Richmond County); under the provisions of O.C.G.A. § 34-9-15. Accordingly, the following stipulations and settlement agreements are entered into by and between the parties hereto and submitted to the State Board of Workers' Compensation as a full and complete statement of that settlement reached between the parties. NOW, THEREFORE, it is hereby stipulated and agreed by all parties that the Georgia State Board of Workers' Compensation has original jurisdiction over this claim and that no other state, court, or entity has jurisdiction over the Workers' Compensation aspect of this claim. It is understood and agreed by all parties that any disputes, conflicts, or other contested issues arising out of this Workers' Compensation claim and the stipulated settlement of said claim by and through entry of this agreement, shall fall within the exclusive jurisdiction of the Georgia State Board of Workers' Compensation and the laws of the State of Georgia. WHEREFORE, the parties stipulate and agree as follows: 2IPage 1. Claimant herein sustained a compensable Workers' Compensation injury on or about April 1, 2008 while employed by the Employer. Employer has heretofore paid to Claimant weekly indemnity benefits in the amount of $147,659.65 and paid for or on behalf of the Claimant medical expenses in the amount of $92,685.23. As of February, 2016 or before, Claimant has been paid 400 weeks of weekly indemnity benefits to date. 2. On or about February 1, 2016, Claimant filed a request for a catastrophic injury designation and lifetime benefits. The Employer/Insurer has timely objected to said request and the matter is now ready for trial. The parties agreed to mediation in an attempt to resolve some aspects of the claim. Claimant is no longer employed with this Employer. Employer/Insurer contends that the Claimant is not totally disabled solely because of his work-related injury such that a catastrophic designation would be appropriate. 3. Motivated by the desire to resolve issues relating to what, if any, future income benefits the Claimant may be entitled to related to his compensable injury and to obtain a full and final resolution of Claimant's Workers' Compensation claim, the parties have reached a full and final settlement memorialized herein. 4. Claimant, Daniel Dennis Key, agrees and stipulates to release and waive any and all entitlement to any further weekly disability payments provided for under O.C.G.A. §§ 34-9- 260, 34-9-261, 34-9-202, and 34-9-263; and, any and all assessed attorney's fees and/or penalties except as provided herein. Claimant, Daniel Dennis Key, further agrees and stipulates to release and waive any and all entitlement to any rehabilitation services to which he may be entitled from the Employer/Insurer by law. 5. In exchange, the Employer agrees to pay Daniel Dennis Key the sum of $150,000.00 as a lump sum payment. 3IPage 6. In addition to the lump sum payment specified above, the Employer/Insurer further agrees that all authorized medical expenses incurred to the date of this settlement have been paid or will be paid by the Employer/Insurer directly to the party rendering such service. Further, the Employer/Insurer agree to be responsible for continuing medical treatment,provided such treatment is related to the compensable injury of 04/01/2008, is provided by a medical doctor, and is authorized under the Workers' Compensation Act. The parties will petition the Board for a change of physician in the event that a specifically named physician is unable to render services, and the parties cannot agree. 7. The Claimant and the Employer/Insurer stipulate and agree that any dispute which arises as to the payment of medical benefits pursuant to this Stipulation and Agreement including, but not limited to whether such medical treatment is reasonable and necessary, and whether such treatment is related to the on-the-job accident on or about April 1, 2008, shall be presented to and decided by the State Board of Workers' Compensation and no other forum. 8. Excepting only medical benefits as stated above, it is further stipulated and agreed by the parties that the Employer/Insurer shall not be responsible for further compensation benefits to the Claimant over and above the $150,000.00 lump sum payment set forth above, including, but not limited to, temporary partial or temporary total disability benefits, rehabilitation expenses, or permanent disability benefits. Claimant further warrants, agrees, and stipulates that this settlement will also act as a full and complete settlement for any other on-the- job injuries which Claimant has sustained including but not limited to the injuries with an accident date of April 1, 2008. Other than the accident dates specifically referenced herein, Claimant warrants that he has suffered no other injuries arising out of the course of his employment with the Employer. 41 Page 9. In the opinion of the parties hereto, this settlement and stipulated agreement is an adequate reflection of the merits of the parties' respective contentions and gives due regard and consideration to the dispute as to the entitlement of the Claimant for further Workers' Compensation benefits and medical expenses,past,present, or future. 10. It is understood and mutually intended by and between the parties hereto that the foregoing settlement and stipulation shall be forever binding and not subject to modification or change or appeal in any manner so as to increase or decrease the rights and liabilities of the parties hereto. 11. Claimant acknowledges that of the $150,000.00 specified above, he shall receive, following the approval of the Stipulation and Agreement by the Georgia State Board of Workers' Compensation, the net sum of$112,500.00 and his counsel shall receive the sum of$37,500.00 representing 25% of the settlement sum as attorney's fees ($37,500.00); Counsel has agreed to pay his own out of pocket expenses and waives any claim for same out of the Employee's lump sum settlement. Claimant hereby designates his counsel to receive for him and on his behalf the above referenced payment. 12. The parties stipulate and agree that Claimant was born on January 5, 1958, that he is currently 58 years of age and that he has a life expectancy of 1,326 weeks from this date forward pursuant to the CDC's Table 1: Life Table for the Total Population, United States, 2010 found at National Vital Statistics Reports, Vol. 63,No. 7. 13. The sum of $112,500.00 to be received by the Claimant shall be payable to Claimant without commutation of interest and shall represent a negotiated compromise agreement that the Claimant's life expectancy is 1,326 weeks forward from this date and that the settlement herein reached represents payment of$84.84 per week over the balance of Claimant's 1,326 week life expectancy. 5JPage 14. A true and accurate copy of the medical note from Claimant's last visit with his ATP dated March 12, 2016 is attached hereto. 15. Wherefore, the parties hereto respectfully request the State Board of Workers' Compensation to review and investigate the foregoing stipulations and settlement agreement and issue its award it terms of law approving same in full and complete discharge and release of the Employer herein. 16. Claimant stipulates that there are no outstanding child support liens that would prohibit full disbursement of the settlement funds in this case. 17. This settlement is in keeping with the spirit and purpose of O.C.G.A. § 34-9-15 to encourage settlement, constitutes complete and final disposition of all claims and the Board shall not be entitled to enter any award subsequent to such Board approval amending, modifying, or changing in any manner the said settlement, nor shall said settlement be subject to review of the Board under O.C.G.A. § 34-9-104 of the Official Code of Georgia. 18. Attached hereto is the WC-1 for the accident of April 1, 2008 and the attorney fee contract where counsel for Claimant authorizes the attorney's fees set forth above. Claimant's counsel certifies that the out of pocket expenses in the attachment hereto, if any, comply with Rule 1.8(e) of the Georgia Rules of Professional Responsibility and Board Rule 108. Also attached is a completed IRS Form W-9 for the Claimant's counsel. Wage ATTESTATION OF CLAIMANT I, Daniel Dennis Key, certify that I am aware that the approval of the Stipulation and Agreement by the Georgia State Board of Workers' Compensation shall finally and forever conclude my claims for Workers' Compensation benefits against the Augusta-Richmond County Board of Commissioners and Corvel Enterprise Company, servicing agent, excepting only claims for medical benefits which shall remain open, arising from the April 1, 2008 injuries and the result therefrom. Furthermore, the facts contained in the foregoing Stipulation and Agreement are true and correct to the best of my knowledge and belief and voluntarily accepted by me. This S day of 4 4i . 3 , 2016. Claimant: -,, if 2_ -7.5 DANIEL DENNIS KEY Sworn to end subscribed before me this . day of August,2016. 1,4f. 4, N ary Public, ,61-46- /4-1 - --n1 (10/1.4-n.(5 , iktgrz : 0 ,78'-2,0 9 71Page ATTESTATION OF CLAIMANT'S COUNSEL THE ABOVE HAS BEEN READ BY DANIEL DENNIS KEY, HAS BEEN EXPLAINED IN FULL TO DANIEL DENNIS KEY BY ME AS HIS ATTORNEY AND HAS BEEN APPROVED,ADOPTED AND RATIFIED BY HIM IN ALL MATERIAL RESPECTS. • T OMA IALLGOO , JR. Allgood & Mehrhof, P.C. 233-B Davis Road Augusta, GA 30907 Phone: 706/724-6526 Fax: 706/724-0043 E-mail: tomallgood@tomallgood.com Georgia Bar No. 012750 Tax ID No.: 58-1624708 81 Page ATTESTATION OF EMPLOYEIVINSURER'S COUNSEL THE EMPLOYER IN THIS INSTANCE IS SELF INSURED AND THUS DOES NOT HAVE TO COMPLY WITH O.C.G.A. § 34-9-15 AND BOARD RULE 15 BY HAVING SENT A COPY OF THE PROPOSED SETTLEMENT TO THE EMPLOYER PRIOR TO ANY PARTY HAVING SIGNED SAME. Augusta Richmond C•l ty Board of Commissioners By: )(/'-C2-‘6 Char s .S. Lyons, t.'e Bar No. 462340 Attorney for Employer/Self-Insurer and Servicing Agent 336 Telfair Street Augusta, Ga 30901-2450 Phone: 706/724-6517 Fax: 706/724-9954 E-mail: charleslyonslawoffice@comcast.net 91Page WC-1 EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE GEORGIA STATE BOARD OF WORKERS' COMPENSATION EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE NOTE:FAILURE TO SUAMIT THIS REPORT TO INSURER IMMEDIATELY MAY RESULT IN PENALTY.MUST BE TYPED OR PRATED 8i BLACK INK Boord Claim No. Employee Lard Name Employes Fist Name MJ. Sodnl&murk,Number 04/01/08 4/ of Injury Key Daniel D. AMP 04/00 1/08108 A. IDENTIFYING INFORMATION 18/ Mate 1 trettasse Phone Number EMPLOYEE 0 Female 01/85/58 706-6649774 Employee AddressCity Stem Zip Code 111Mopte Creek Drive Martinez GA 30987 EMPLOYER Name IWN.M.S Code Nabof Business(b ,Mc. (Trade,Transport seg ) Angliata Richmond Coaely Commission Government Address Phone Want Employer FEIN 530 Greene Street,Room 217 706-821-2382 W7 Stab Zip Code Eautoyer Ewell Augusta GA 30901 Ibbekatoae®aRgastaga,gev INSURER/ Nam. InsureatiNnsursrFEIN Linsured8.11-aur'SELF-INSURER Aerate Ri hmondCountyCommission 10620001190 C'A'"°OFFICEName Gama Once s Winn Moe Pion e hime Otece linesSeedGeorgia Administrative 770.963.7732 esglish aadminsva.com SSWC IDs(Sea dipn no.) Address OD Zip Code 21676 1775 Spectrum Drive I Lawrenceville GA 30043 Dar NMd by Empoyr Job Cleseibd Code No. Number of Dari Waited Pore** Wage Me M inn of ❑ per Hour EMPLOYMENTWMGEe ay or DiseDisease: ❑ ter Oma' Deputy l X20) 03/!6187 31454,44 13PrWeak NmaurerTypo Code UM Nadh Se/sedated ted DaysI m Blweebly I_Insurer ❑ 5-Sell-insurer OS-Guarantee Fund Sat-Sunday ❑ par month INJURY/ILLNESS TMs etInMy Com'of 'y Data Enadomr a and raWadoe of Ent er PIM r Date Employee Failed loWant &MEDICAL 0800 Hn 0 Peen/ in Burke Comely 04/01/08 84102!08 Old Employee Receive FW Did Mpry!>nets Occur Type of edwyAlia.. Body Pan Madrid Pay en Dais at NOW en Employ?.preem.es? ® yg ❑ No ❑ yin ® No contusions/pain Hcad,Chess,other area body How itiwy or Mess/Abnormal Health Condeon Oeaar d Involved lei saddest on Hwy 56,13 miles south of Waynesboro Treading Physician(Noma and Address) Wt.l Trmbeeemt Give= Hospital lTrsiq Poo ip(Nuns and Address) MCG Hospital ER 0 NoneMCG H Returned r worts Grve Caws 04/22/08 ❑ fin by Enolover Argun,GA 30901 0 Mnen cieveasHoepar 706 721-4951 Rimmed sop same preach ® Emergency Room a Faw,Enter CoMIIMM ❑ i"Pledizad'2dIrs Data of Death RpatPrepared By(Print r1,ps) Terpton.Ember Delict Report Sgt.Vincent Eubanks 7064521-1458 04/08(08 B.INCOME BENEFITS Fonn WC-6 must be filed If weekly benefit Is less than mexknum Pfrooudy mooed 0 eYY O�N (o 1 Average Weekly wagerS 726.17 Weekly benefit:$ 484.13 Dar of dreamily!_ 04102(08 Dab of first Payment Compeenatbn paid$ 871.43" 4/4/08 E BENEFITS ARE PAYABLE FROM 4/9/08 ►�, / i I/ A CL_ i. 0 Temporary total di:wa ty 0 Temporary partial daablilty ❑ atOM dssd0ly of ✓% to for weeks. UNTIL 4/22/08 WHEN THE EMPLOYEE ACTUALLY RETURNED TO WORK WITHOUT RESTRICTIONS.ALL OTHER SUSPENSIONS REQUIRE THE FILING OF FORM WC-2 WITH THE STATE BOARD OF WORKERS'COMPENSATION AND THE EMPLOYEE. C.NOTICE TO CONTROVERT PAYMENT OF COMPENSATION Senate user not be pied became: ID.MEDICAL ONLY INJURY ❑ No disability paid der Controverted. .�R (Insurer/SMf4reur.Type or Print Nems of Parson Rena roan) / Sarah English /tea/ ` /` . 1nigh Phone and Ei4 6-nail C/LL / L'l 678-325-2664 aeaglI, gaadmiaevcs tomWS Zg IF YOU NAVE miswrote nesse CONTACT THE STATE BOARD OP WORKERS'COMPENSATION AT 4014044111 OR 1400.433402 OR Ills RMLLPULLYWONG A MLLE STATe UIT FOR VIEPOAPOM Of OSTAaINI OaO.NTINO auMVh.IA A OMB IVILNICT 70 MALT'S.Of UP TO sw..s.Y PER VIOLA Z " 01.V.:71), EMPLOYER'S FIRSTr' •F INJURY WC-1 REVISION.07/2007 OR OCCUPATIONAL.DISEASE 1 OF 2 Jill P. Hauenstein, MD Psychiatry 2324 Washington Road Augusta, Georgia 30904 PO Box 3474, Augusta, GA 30914 Phone/Fax:706-733-7029 March 12,2016 Re:Daniel Key SSN: To Whom It May Concern: Mr.Key was my patient in the past.He recently moved away and has seen another psychiatrist but is unhappy with his treatment there.He came for an appointment recently and expressed a desire to start coming back to me for treatment,despite the travel Involved. In the past he was diagnosed with PTSD from a motor vehide accident in which two prisoners he was transporting were killed by a truck colliding with his car.He suffered injuries to his head and back in the crash.Since then he has had back pain,severe headaches,nightmares,occasional confusion,startle responses—especially when in a car and seeing something approaching from the right,as happened in his accident—and has been unable to drive except for very short distances. It is my opinion that he is still suffering from PTSD and survivor guilt,and in incapable of holding a job.if you have need of any further information,please do not hesitate to contact me. Jilt P.Hauenstein,MD Jha/JPH a AUTHORITY TO REPRESENT I hereby employ ALLGOOD&MEHRHOF,as my attorneys to represent me in my claim for workers compensation benefits under Georgia law against AUGUSTA RICHMOND COUNTY GEORGIA and others resulting from a work- related injury on or about APRIL 1,2008. As compensation for their services,I agree to pay my attorneys all fees authorized by the Georgia Workers Compensation Act and/or the Rules of the Georgia State Board of Workers Compensation,subject to the approval of the State Board of Workers Compensation prior to payment of any such fees,plus all out-of-pocket expenses incurred by my attorneys in handling my case,including butnot limited to travel expense,court reporter fees,telephone costs, expert witness fees,and all other litigation expenses.In no event shall attorney fees, exclusive of expenses,exceed 25% of any indemnity (TTD, It'll or PPD)benefits I may receive. dt-- ---------- This I day of dL w.`(--a r t ,2016. C/t-Ci7.-J6 . IENT Name: Daniel D.Key SSN: MINIIMIS The above employment is accepted upon the ms stated therein. / / r 1 1..L OMAS r(ALLGOOD,JR. AUTHORITY TO REPRESENT I hereby employ ALLGOOD &MEHRHOF,P.C.as my attorneys to represent me in my claim for workers compensation benefits under Georgia law against AUGUSTA RICHMOND COUNTY BOARD OF COMMISSIONERS and others resulting from a work-related injury on or about April 1,2008. As compensation for their services, I agree to pay my attorneys all fees authorized by the Georgia Workers Compensation Act and/or the Rules of the Georgia State Board of Workers Compensation,subject to the approval of the State Board of Workers Compensation prior to payment of any such fees,plus all out-of-pocket expenses incurred by my attorneys in handling my case, including but not limited to travel expense, court reporter fees,telephone costs,expert witness fees,and all other litigation expenses. In no event shall attorney fees,exclusive of expenses,exceed 25% of any indemnity ( TU, TPD or PPD)benefits I may receive. This /I day of it 6 u a y ,2009. (61,),a49-9-, 74A CLIENT Name: DANIEL KEY SSN: The above employment is accepted upon the terms stated therein. THO ALLGOOD,JR. �mn W-9 Request for Taxpayer Give Form to the (Rev.December 2011) Identification Number and Certification requester.Do not Ds Rnt uheesTrear a send to the IRS. intName(as shown on your income tax return) ALLGOOD&MEHRHOF,P.C. Business name/disregarded entity name.If different from above Check appropriate box for federal tax claeeNication o ❑IndividUOVsoie proprietor ✓❑ C Corporaton []S Corporation 0 Partnership 0 Tnatrestete 0 Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P•.partrrerehip)! ❑Exempt payee ❑ Other(sea instructions)b- --_—.---...__..__�_._�_ Address(number,street,and apt.or suite no.) Requester's name end address(optlonaq & 233-B DAVIS ROAD City,state.end ZIP code rc• AUGUSTA.GA 30907 Liat account nxnber(s)hem(optional) Part I Taxpayer Identification Number(TIN) Enter your TIN in the appropriate box.The TIN provided must match the name given on the"Name'line I Sociai security number to avoid backup withholding.For individuals,this Is your social security number(SSN).However,for a resident alien,sole proprietor,or disregarded entity,see the Part I Instructions on page&For other entitles,it Is your employer identification number(EIN).if you do not have a number,see Now to get a TIN on page 3. Note.if the account Is in more than one name,see the chart on page 4 for guidelines on whose f Employer identification number 1 number to enter. s s — 1 6 2 4 7 0 8 Part II Certification Under penalties of perry,I certify that: 1. The number shown on this form is my correct taxpayer identification number(or I reit waiting for a number to be issued to rare),and 2. I am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the internal Revenue Service(IRS)that i am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am no longer subject to backup withholding,and 3. I am a U.S.citizen or other U.S.person(defined below). Certification Instructions.You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup holc#ng because you have faked to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage Interest paid,acquisition or abandonment of secured property,cancellation of debt,contribution to an indhddual ret cement arrangement(IRA),and generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the instructions on page 4. Sign signatory or Here U.S.person 1- `i/ Dates 7/ f 2'�" General Instructions Note.If a requester gives a other than Form W-9 to request your TIN,you must use the requester's form if it is substantially similar Section references are to the Internal Revenue Code unless otherwise to this Form W-9. noted. Definition of a U.S.person.For federal tax purposes,you are Purpose of Form considered a U.S.person if you are: A person who Is required to file an Information return with the IRS must •An individual who is a U.S.citizen or U.S.resident alien, obtain your correct taxpayer identification number(RN)to report,for •A partnership,corporation,company,or association created or example,income paid to you,real estate transactions,mortgage interest organized in the United States or under the Taws of the United States, you paid,acquisition or abandonment of secured property,cancellation •An estate(other than a foreign estate),or of debt,or contributions you made to an IRA. •A domestic trust(as defined in Regulations section 301.7701-7). Use Form W-9 only if you are a U.S.person(Including a resident Special rules for partnerships.to provide your correct TIN to the person requesting k(the P rships.Partnerships that conduct a trade or requester)and,when applicable,to: business in the United States are generally required to pay a withholding 1.Certify that the TIN you am giving is correct(or you are waiting for a tax on any foreign partners'share of Income from such business. Further,in certain cases where a Form W-9 has not been received,a number to be issued), 2.Certify that you are not subject to backup withholding,or partnership to presume o that,a youpararener a a U.S.fopersonpethat pay the withholding tax.Therefore,if you are a Sthat Is a 3.Claim exemption from backup withholding If you are a U.S.exempt Partner in a partnership conducting a trade or business in the United payee.If applicable,you are also certifying that as a U.S.person,yoitr States,provide Form W-9 to the partnership to establish your U.S. allocable share of any partnership income from a U.S.trade or business status and avoid withholding on your share of partnership Income. is not subject to the withholding tax on foreign partners'share of effectively connected Income. Cat No.10231X Form W-9(Rev.12-2011)